IV. Comparação das técnicas cirúrgicas de resolução da RLCCr – Análise estatística dos
4. Conclusão
O objectivo da presente dissertação centrou-se na comparação entre técnicas cirúrgicas para a resolução da ruptura do ligamento cruzado cranial em canídeos, com base numa amostra de doentes intervencionados cirurgicamente no Hospital Escolar da FMV. Essa amostra incluiu três grupos de técnicas: TTA, técnicas extra-capsulares e técnicas intracapsulares. No grupo das técnicas extra-capsulares foram incluídas várias técnicas, e registou-se apenas um caso de técnica intracapsular, pelo que a comparação dos seus resultados com a TTA (técnica mais representada) se tornou difícil. Teria sido interessante que o estudo efectuado tivesse incluído mais pacientes das técnicas menos representadas, de modo a equilibrar o número de doentes submetidos a cada uma delas, e permitir um estudo mais relevante. Também os dados obtidos foram insuficientes para uma análise mais aprofundada. Outro aspecto relevante em estudos de patologia do foro ortopédico é a consistência da anamnese e exame clínico, visto que os achados dependem em grande parte da experiência do ortopedista. Como os dados foram colhidos a partir das fichas clínicas dos pacientes, fichas essas que são preenchidas tanto por alunos dos 3º, 4º e 5º anos, bem como pelos estagiários, Médicos Veterinários de Medicina Interna, para além do Cirurgião Ortopédico, a consistência desses registos acaba por se perder, tornando mais difícil a análise dos dados. Também o tipo de escalonamento durante o estágio tornou difícil o seguimento dos pacientes em estudo, tendo ocorrido, em alguns casos, o contacto com os doentes em apenas um momento do seu seguimento no Hospital Escolar. Apesar destas dificuldades, o estudo e caracterização desta amostra permitiram a discussão de alguns aspectos relevantes.
A RLCCr é uma das patologias ortopédicas mais frequentes em canídeos (Johnson et al, 1994), para a qual, até à data, não existe uma resolução cirúrgica que se revele como a mais eficaz em termos de tempo de recuperação pós-cirúrgico, função final do membro afectado e progressão da DDA. Contudo, existe uma tendência actual para a valorização e aposta nas técnicas que fazem uso da estabilização dinâmica, ou seja, das osteotomias tibiais. Assim, actualmente a Tibial plateau leveling osteotomy é considerada, na generalidade dos ortopedistas veterinários, como o gold-standard para a correcção da RLCCr. Também a Tibial
tuberosity advancement começa a ganhar importância, sendo mesmo defendida por alguns
autores como uma alternativa melhor do que a TPLO. Não existem contudo estudos objectivos que provem a vantagem quanto ao resultado a longo prazo das osteotomias tibiais face às técnicas intra e extra-capsulares tradicionais (Conzemius et al, 2005). As diferenças individuais e inter-rácicas em termos de morfologia, cinemática e cinética podem também contribuir para o resultado final da cirurgia, revelando-se algumas técnicas mais apropriadas a
determinadas raças e tipos de conformação tibial. É por este facto que o conhecimento mais aprofundado da complexa biomecânica do joelho se torna fundamental no discernimento e análise da eficácia das diferentes técnicas cirúrgicas (Kim et al, 2008).
Neste estudo a principal diferença observada entre as técnicas, foi no tipo de complicações ocorridas no período pós-operatório. Ambos os grupos da TTA e das técnicas extra-capsulares apresentaram uma taxa de complicações bastante elevada, mas as complicações observadas no grupo da TTA foram menos graves, e não necessitaram de segunda cirurgia, enquanto que o inverso se passou com o grupo das técnicas extra-capsulares. Quanto ao tempo de recuperação e de início do apoio do membro afectado, os pacientes submetidos a técnicas extra-capsulares revelaram-se mais precoces, mas vários factores poderão ter influenciado os resultados, nomeadamente, o facto de grande parte dos doentes submetidos a TTA apresentarem doenças ortopédicas concomitantes, e também o facto de alguns pacientes do mesmo grupo terem sofrido complicações que terão atrasado a cicatrização do local intervencionado.
Todo o processo de elaboração deste estudo revelou-se uma aprendizagem importante, principalmente quanto à estruturação de um estudo clínico, e dos passos prévios a dar, quanto à colheita de dados. A experiência adquirida com a elaboração desta dissertação será importante no futuro profissional, e útil para a produção de trabalhos científicos, ferramenta fundamental na difusão e progressão dos conhecimentos nesta profissão.
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